Why “Buzzed Driving” is not “Drunk Driving”: A Look at a Misleading Driving Under the Influence Campaign – Amber Solivan

Alcohol related motor vehicle accidents account for approximately 40% of all motor vehicle deaths. This is a prime public health concern as an additional 18,000 deaths would be prevented if drivers did not drive while intoxicated. Men that are involved in a motor vehicle accident are twice as likely as women to be intoxicated. Persons aged 21 to 34 comprise the highest percent of persons driving under the influence however men aged 18 to 21 reported driving under the influence more frequently than any other age group. Additionally 159 million people self-reported driving while intoxicated however only 1.4 million drivers were arrested for this offence (1,2).

The effects of alcohol on driving safety were not studied in the United States until the 1930’s. Initial observations were made in 1934 by Heise about how alcohol impairs driver judgment and overall safety; however, it was not until 1968 that the US Department of Transportation and National Highway Traffic Safety Administration (NHTSA) began reviewing alcohol-crash associations and initiating ways to try to prevent alcohol related vehicle crashes (3). Over time many different campaigns have been used to educate and prevent alcohol related car accidents and deaths. In 1992 the US Department of Transportation and the NHTSA began the most historic and well known anti-drunk driving campaign “Friends Don’t Let Friends Drive Drunk” (FDLFDD) (4). Although this campaign brought drunk driving levels to historic lows in the late 1990’s the incident of deaths from drivers with a BAC over the legal limit rose from 13,000 in 2004 to 15,000 in 2006 (3,5).

In response to the rise in drunk driving deaths the NHTSA commenced a new campaign in 2005, “Buzzed Driving is Drunk Driving” (Buzzed Driving). This campaign used public service announcements (PSA) on TV and radio as well as billboards. It is unclear exactly what the message was, but I believe the message is that if you feel “buzzed,” you are impaired and over the legal limit. Statistically significant data about the direct success of the campaign is not readily available however since 2005 there has been no change in the number of drunk driving accidents and there has been an increase in the number of drunk driving deaths. The campaign sought to build on the success of the FDLFDD campaign however it was a flawed public health intervention because of its failure to provide a clear and accurate message. The campaign also failed to account for social norms surrounding social drinking in the US population, especially among 21 to 34 year olds. Finally the campaign used properties of an inappropriate model.

Buzzed Driving Campaign Failed to Relate a Clear Message
An essential part of a public health campaign is that the target audience understands the message that is being conveyed. The Buzzed Driving is Drunk Driving campaign failed to relate a clear and strong message causing confusion and misleading the audience. The TV PSA used for this campaign consisted of two categories of people aged in their early twenties to their mid thirties. The first category is someone that is clearly over the legal limit and is shown moving with impaired motor skills, and acting uninhibited. The second category is someone that takes a few sips of a drink that is still half full and then picks up their car keys to drive home. The PSA is making the inference that the person taking that “last sip” from a partially full drink is “buzzed” and should not drive home, however because there are not multiple empty glasses shown and the drink that is being drank from is still half full the visual message being portrayed is that having any alcohol before driving is illegal, which is untrue.

When the NHTSA launched this campaign they sought to address the impaired driver with the message that if you have had enough to drink to feel “buzzed” or in any type of altered state than you are too impaired to drive (2). However neither the NHTSA nor any other organization has defined the feeling of a “buzz” for the population. The concept of a “buzz” is undefined but is a term used in popular culture to describe someone’s physical state in relation to impairment. Intoxication is measured by the amount of alcohol in your blood commonly referred to as a blood alcohol concentration or level (BAC). The BAC is a percent of alcohol in your blood stream measured by the weight of alcohol in a certain volume of blood at a certain point in time and reflects the amount of alcohol you consumed within 30 to 70 minutes (4). There is not a BAC to reflect a “buzz,” nor is there a certain level of impairment that coincides with a “buzz”. Research has shown that at a BAC of 0.02% an individual may experience a relaxed state and visual function may decline, while at a BAC of 0.05% the person may have exaggerated behavior and experience reduced coordination (4). However neither of these BACs and the resulting impairments was associated with a “buzz” in the campaign message. Therefore, the campaign is in essence leaving it up to the individual to determine their limits and their ability to drive, the campaign is not educating the audience. The audience already knows that drinking to intoxication can lead to impaired judgment possibly leading to motor vehicle accidents, arrest, or even death. They have been determining their own limits yet they have been choosing to drive with a “buzz”. Further these are consequences known by a rational population; however, someone who is impaired is not rational and therefore is unable to make these associations. If the issue being addressed by the campaign is actually “buzzed”= drunk than the social norm definition of “buzzed” needs to be changed by the PSA. If the issue being addressed by the campaign is actually “buzzed”= impaired and impaired=dangerous than the social norm of no drinking and driving must be changed by the PSA. Neither of these issues was addressed by the PSA.

Further misdirection of this campaign can be seen when researching the reactions of people after the campaign was launched. A popular legal blogger, Blonde Justice, made this statement on her blog, “The point of this ad campaign, I believe, is to draw the following line of thought: Buzzed Driving = Drunk Driving = Illegal...Therefore, Buzzed Driving = Illegal[…]It's a clear misstatement of the law…it is only illegal to drive while legally intoxicated.”(6) The Idaho Transportation Department misinterpreted the definition of impairment and interpreted the PSA similarly to the blogger as buzzed driving is illegal, they failed to clearly state the purpose of the campaign or interpret the word buzzed (7). A prominent news caster from ABC Laura Marquez, translated “impaired” as anyone with a BAC above 0.08% (8). Unfortunately this important message about impairment was lost on ineffective advertising and inconsistent messages. Different BACs lead to different levels of impairment, this important information was missing from the campaign and could have been used to strengthen or at least clarify its message.

Buzzed Driving Campaign Fails to Account for Social Norms
Consuming alcohol with friends and family is a social norm in this country and many other countries. The Buzzed Driving campaign makes the implication that consuming an alcoholic beverage and driving is equivalent to drunk driving. The NHTSA assumes that individuals at a social function where there is consumption of alcohol will perceive themselves as being at risk. This perception of individual risk contributes to the campaign’s failure to define “buzzed” for the audience and the audience’s failure to establish safer personal limits. Many people do not feel that they can or want to attend various social functions and not consume any alcohol because it is part of their social norm. Therefore because they do not desire not to drink they will most likely continue with the assumption that they know their limits and not pay close attention to how many drinks they have had. In the perceived threats theory an individual must feel that a particular behavior or action will be a threat to them. In this instance 159 million people drove under the influence and only 1.4 million were arrested in 2006 (1), even more people have at one point had a drink and driven and they have not had adverse consequences, therefore in this case the perception of danger must be changed for the behavior to change.

Social norms have a strong influence on how people behave. The relationship between social norms and drinking has been studied extensively. Multiple studies have been conducted and shown that people often overestimate the alcohol consumption of their peers which encourages an overall increase in their own alcohol consumption (9). The Buzzed Driving campaign does not address this social norm and is especially flawed due to the misleading visuals of the campaign. One PSA used depicts a man getting ready to leave a wedding. Among drinkers, it is a social norm to drink at a celebration, in this case a wedding where the social norm often includes a champagne toast. The misleading visuals of the PSA suggest that it is not safe to have a drink at a wedding and then drive home. The social norms would not agree with this deduction, as many people have had a drink and drove and not suffered consequences, and therefore this campaign fails.

In addition to effect of perceived alcohol consumption, research performed on college campuses across the country have shown that college students were more likely to drink and to drink to intoxication based upon the social event and celebration they were attending (10). Studies have also shown that the amount of drinking on campus can be decreased by distributing accurate information on the amount of alcohol that is actually consumed by the other students, which is frequently less than their peers expected (11). These social norms identified among college students may be applied to the social norms among the general population on a lesser scale where celebratory drinking is the practiced norm and as such individuals are not likely to feel the need or desire to deviate from this norm. Drunk driving statistics support this as 21 to 34 year olds that are still drinking to excess and driving which matches their college counterparts on these occasions.

Buzzed Driving Campaign Misuses of Models
The Buzzed Driving campaign used aspects of the health belief model (HBM) which incorrectly assumes that intention is a direct predictor of behavior. It also used the theory of planned behavior (TPB) which incorrectly focuses on rational and reasoned behavior by the individual. The HBM does not take into account influences on decisions such as learned behavior and perceptions surrounding drinking. The HBM also does not account for the social norms surrounding drinking previously discussed.

The principles the campaign uses from the HBM fail to account for the social influences and norms that surround individuals. Social influences include those influences and norms felt by society and by one’s peer group. As stated previously it is well documented that persons who perceive their peers as drinking heavily will they themselves drink heavily (12). Additionally it has been found that norms predict drinking; however, drinking does not predict the perceived norms (12). Therefore if the perceived norm is changed the behavior will change. The behavior will not change the norm.

The principles the campaign uses from TPB assumes that those who have been consuming alcohol will rationally consider their decisions. This model assumes a high level of rational thought by the individual which is contradictory to being under the influence of alcohol. Research performed by the NHTSA indicated that judgment becomes impaired with a BAC as low as 0.02%. The campaign takes for granted that an individual who is “buzzed” would be able to understand their level of impairment. This level of rational thought may be a reason that the FDLFDD campaign was so successful; the responsibility was in the hands of someone who was thinking rationally and not in that of the impaired.

Conclusion
The Buzzed Driving campaign potentially holds an important message to all drivers; although the intended message is unclear, it potentially holds that driving when you feel any effect of alcohol is impairment and is dangerous. The NHTSA was very successful in bringing to light the dangers of drunk driving; however the NHTSA’s “Buzzed Driving is Drunk Driving” campaign is a flawed public health intervention because it failed to convey a clear and therefore compelling message. This unclear message was compounded by the neglect to account for social norms surrounding drinking at social occasions. The campaign was also flawed because it used aspects of inappropriate behavioral models that lead to its lack of efficacy. It is unclear whether the NHTSA was trying to change the social norm of consuming any alcohol and then driving. This lack of clarity in message further negates the merits of this campaign.

REFERENCES
1. Centers for Disease Control and Prevention. Impaired Driving. Atlanta, GA. http://www.cdc.gov/ncipc/factsheets/drving.htm
2. National Highway Traffic Safety Administration. Traffic Safety Facts: 2006 Traffic Safety Annual Assessment – Alcohol Related Fatalities. Washington, DC: NHTSA’s National Center for Statistics and Analysis, August 2007.
3. US Department of Transportation. National Highway/Traffic Safety Administration. Alcohol and Highway Safety 2001: A Review of the State of Knowledge, 2001.
4. Ad Council. Drunk Driving Prevention. http://www.adcouncil.org/default.aspx?id=49
5. National Highway Traffic Safety Administration. The ABCs of BAC: A Guide to Understanding Blood Alcohol Concentration and Alcohol Impairment. Washington, DC, 2005.
6. Blonde Justice. Buzzed Driving is…Legal. No location, 2005. http://blondejustice.blogspot.com/2005/12/buzzed-driving-is-legal.html
7. Idaho Transportation Department. ITD reminds drivers that "buzzed" driving is drunk driving this St. Patrick's Day. Boise, Id: Office of Highway Operations and Safety, 2007.
8. Marquez, Laura. Buzzed Driving is Drunken Driving. ABC News.com, December 28, 2005.
9. Dunnagan, T., Haynes, G., Linkenbach, J, Summers, H. Support for Social Norms Programming to Reduce Alcohol Consumption in Pregnant Women. Addiction Research and Theory,August 2007; 15(4):383-396.
10. Glindermann, K., Wiegand, D., Geller, E. Celebratory Drinking and Intoxication. Environment and Behavior, 2007; 39(3): 352-366.
11. The Higher Ed Center. The Social Norms Approach: Theory, Research and Annotated Bibliography: What is the Effect of Correcting Misperceptions? Successful Interventions Utilizing the Social Norms Approach. August 2004. http://www.higheredcenter.org/socialnorms/theory/interventions.html
12. Neighbors, C., Dillard, A.J., Lewis, M.A., Bergstrom, R.L., and Neil, T.A. Normative Misperceptions and Temporal Precedence of Perceived Norms and Drinking. Journal of Studies on Alcohol, 2006, 67(2): 290-299.

Got Fear?: The Failures of The Health and Human Services Campaign to Overcome the Barriers to Breastfeeding – Elmy Trevejo

The benefits of breastfeeding have been well documented for years. It is believed that breastfeeding saves 5-6 million children’s lives annually. According to the Lancet Child Survival Series, it is estimated that 1.3 million additional lives could be saved annually if women were enabled to achieve six months exclusive breastfeeding with continued breastfeeding thereafter (6). Infants that are not breastfed have decreased survival rates due to physical conditions such as NEC (necrotizing enterocolitis), diarrhea, respiratory illnesses, sepsis, and pneumonia. Bottle fed infants are more likely to suffer from otitis media, atopic dermatitis, gastroenteritis, and asthma (5,6,11). Other studies have found that infants that are bottle-fed may be more susceptible to increased cardiac risk factors such as obesity, diabetes and childhood leukemia (6). The benefits to the mother are quite substantial as well, and include decreased risk of breast cancer, ovarian cancer, and type two diabetes mellitus. There is also an association between breastfeeding and decreased cases of post partum depression (6, 12).
“ ...[Breastfeeding] represents the normal and expected way to feed infants and young children, yet continues to suffer from cultural and commercial barriers that make it difficult for mothers to adhere to the medical recommendations to breastfeed exclusively for six months, and to continue breastfeeding with appropriate complementary foods for one year and beyond (15, p. 552).”

Breastfeeding rates in the United States are considerably lower than in other parts of the world. The American Academy of Pediatrics recommends that women breastfeed for >12 months, and thereafter for as long as mutually desired (13). The latest data compiled by the Center for Disease control states that in 2004, the rates for breastfeeding early postpartum, at six months, and at twelve months was 73.8, 41.5, and 20.9, respectively. US Healthy People 2010 target is to increase the proportion that breastfeed their babies at birth to 75% and for six months to 50% (12). As a public health initiative the Department for Health and Human Services developed a marketing campaign to address this growing public health crisis.

The campaign featured two television ads, radio spotlights, and print media coverage. The commercials, which aired from June of 2004 to December of 2005, became the center for significant controversy due to the manner in which HHS targeted the audience. The first commercial shows two women, late in their pregnancies, in a logrolling competition. A message is briefly displayed on the screen that states, “You wouldn’t take risks with your baby before their born. Why start after?” The logrolling women are then back on the screen, and a voiceover states that studies show that babies that are breastfed for six months are less likely to develop ear infections, respiratory illnesses, and diarrhea. The end of the commercial shows the final message, “Babies were born to be breastfed.” The second commercial that HHS created depicted a woman in her third trimester being helped on top of a mechanical bull, and riding it until she falls off. The same message is displayed, “You wouldn’t take risks with your baby before their born. Why start after?” The same voice over is heard that quickly states some of the benefits of breastfeeding. In this paper, I am going to discuss the reasons that the HHS campaign for breastfeeding failed to be an effective public health initiative. The Health and Human Services campaign failed to be an effective public health initiative because it 1) uses a scare tactic/bullying approach, 2) fails to address the barriers that new mothers face that may hinder their compliance, and finally 3) the campaign fails to address the growing duality that exists between women and their bodies in American culture.

The Health and Human Services campaign uses a scare tactic approach towards breastfeeding
This tactic is discussed in the Protection Motivation Theory developed by Rogers in 1983. Protection motivation theory was first developed within the framework of fear-arousing communication. As stated by Boer and Seydel, protection motivation is the result of the threat appraisal and the coping appraisal. The appraisal of the health threat and the appraisal of the coping responses result in the intention to perform adaptive responses (protection motivation) or may lead to maladaptive responses. Protection motivation is a mediating variable whose function is to arouse, sustain and direct protective health behavior. It facilitates the adoption of adaptive behaviors and can best be measured by behavioral intentions (2). The HHS campaign uses this tactic in order to “frighten” their audience. The assumption is made that if knowing that one is causing harm to their child, mothers will be more apt to adopting breastfeeding practices. This is the major flaw in the campaign. The campaign uses callous blaming in order to get the audience’s attention. The message that is portrayed is that women who choose not to breastfeed are essentially harming their children, and goes as far as to compare it to dangerous activities such as mechanical bull riding, and logrolling. Although the message is supposed to be humorous, the underlying message is riddled with blame and has a tone of judgment that is not effective.

The campaign, in essence, labels women that bottle-feed as “bad mothers” or mothers that do not care about the well being of their children. The strategy used was designed to notify the public that on all counts breastfeeding is better for infants. The problem is that the campaign assumes that people are unaware of this. Studies have shown that when asked, non breastfeeding mothers state that they are aware that breastfeeding is superior to bottle-feeding, but the barriers that they faced to breastfeed outweighed the potential benefits. As stated by the HHS in June of 2004, “Research has shown that many women know that breastfeeding is the best nutrition for babies. This knowledge has not translated into changed behaviors, and breastfeeding rates have hit a plateau.” Pregnancy and birth are highly stressful and anxiety provoking events for most women, and instead of trying to empower and encourage women to embrace breastfeeding for the numerous benefits that it has, the HHS campaign bullies women into feeling like “incompetent mothers,” if they choose not to breastfeed.

The Campaign fails to address professional and social barriers
Another issue that I have with the HHS campaign is that it fails to address any of the barriers that women face when making the decision to breastfeed or bottlefeed. One of the biggest barriers that women face is related to lack of support in the workplace, and shortened maternity leave. One third of mothers return to work within three months of having a baby, and two thirds return within six months from birth (14). As stated by C. Barona-Vilar, “Among employed women, structural support linked to working conditions has a decisive role on breast-feeding election and duration. Duration of breastfeeding tends to be longer when maternity leave is longer, especially among women with higher professional qualifications and permanent contracts. Among women with lower professional qualifications, and women whose high level of precarious work and low income converges, breast-feeding duration is substantially reduced (1)” The United States guarantees three months of unpaid maternity leave. When compared to other countries, this is appalling. In Norway, more than 97% of women breast-feed their infants during the immediate postpartum period, 80% continue at 3 months, 20% breast-feed beyond 12 months. Women can take maternity leave for 42 weeks with full pay or for 52 weeks with 80% pay. After returning to work, they are entitled to 1-1 ½ hour breaks each day to feed their infant (13). Many women are forced back into the workplace early because they are unable to go without the additional income, adding another layer of complexity to breastfeeding their infants.

Another complaint that new mothers have is regarding the stigmas regarding workplace pumping. As suggested by Caroline Jane Gatrell, “mothers face hostility if they breastfeed infants, or express milk, within workplace spaces. Consequently, shortened breastfeeding duration rates among employed mothers have attributed to organizational discouragement (3). It was originally suggested by Witters-Green that even where employers are aware of the issues, they fail to offer suitable spaces for breastfeeding. This is partly for cost-related reasons but also because employers are ‘discomfitted’ and ‘offended’ by the idea of breastfeeding mothers (14). There are false perceptions regarding breastfeeding in the workplace. Women often choose not to continue breastfeeding after returning to work, because of the way they feel their coworkers will react (8). In this country, breastfeeding has become something that should be hidden and done discretely, in order to keep everyone comfortable, instead of acknowledging it as a natural and biological necessity. Some women even feel that if they were to breast feed or expel milk at work, their professional life would suffer from negative consequences. Without addressing these concerns, the message of the HHS campaign is useless. It is easy for the campaign to blame women for their inability to care for their infants appropriately, but we as a society need to change policy and the workplace environment to assist and encourage women to feel that breastfeeding is socially acceptable.

The Campaign fails to acknowledge the dichotomy between breastfeeding and sexuality
It is well known that in Western cultures, breasts have become increasingly oversexualized. The social norm has changed the focus of the breast from its biological function to a sexual male fetish. As stated by Iris Young in her essay, Breasted Experience, “To be understood as sexual, the feeding function of the breasts must be suppressed, and when the breasts are nursing they are desexualized. A great many women in this culture that fetishizes breasts are reluctant to breastfeed because they perceive that they will lose their sexuality. They believe that nursing will alter their breasts and make them ugly and undesirable (17, p. 199).” This process may contribute to the reason women choose not to breastfeed. If women are afraid that by breastfeeding they are in essence “desexualizing” themselves, they are less likely to adopt the behavior. They are more likely to view the behavior in a negative way. The dichotomy that prevails creates a disassociation for most women. Although they want to do their best by providing nutrients for their infant, it puts their own sexual identity at risk.

According to Dettwyler, a well-known breastfeeding advocate, she states that the sexualization of women’s breasts underlies the taboo against breastfeeding in public. “It is ironic that breastfeeding an infant in public is still widely frowned upon, denying the natural function of the breasts at the same time as objectifying them for the sexual gratification of men” (3, p. 204). Women are concerned that they will no longer be considered attractive to their male partners. A survey conducted by Ward in December 2006, found that men were more likely to endorse traditional gender ideologies that portray men as sexually driven, and women as objects of sexual desire. It was difficult for men to accept the duality of female sexuality, and the biological need to provide nutrition for their infants. “These findings support the notion that traditional masculine ideation focuses on the sexual aspect of women’s breasts and bodies, thereby making it more difficult for men to embrace the reproductive functions (16).”

The failure of the HHS campaign is that it does not acknowledge that this duality exists. As long as women’s bodies are objectified to the degree seen now, it will be extremely difficult to change breastfeeding compliance rates without addressing the root issue. In our society, we do not object to media shots of women in skimpy outfits that accentuate their breasts, but we become very uncomfortable with the image of a woman nursing. Western culture continues to see the breast as an object for sexual gratification, and has made any other views of the breast perverse. The Health and Human Services campaign fails to broach the social stigma that our culture has towards a “desexualized” breast. It fails to acknowledge the dichotomy, and therefore cannot be effective in persuading mothers to breastfeed.

In conclusion, the Department of Health and Human Services breastfeeding campaign fails to be effective due to its judgmental and “bullying” strategy. To combat this public health issue, we cannot alienate and label women as inadequate mothers without addressing the social and professional reasons that contribute to the decision making process. The fire and brimstone campaign approach to breastfeeding is insulting and fails to encourage women to adopt the behavior. Instead of focusing on changing policy and also trying to address the manner in which women now objectify themselves, the health and human services campaign puts the blame and focus on the individual mother. It is obvious that this issue is multi-layered, and must be addressed in that manner, as well.

References
1. Barona-Vilar, C., et al., A Qualitative Approach to Social Support and Breast-feeding decisions, Midwifery (2007) 1:1-8.
2. Boer, H., Seydel, E. Protection Motivation Theory. (95-120) In M. Connor and P. Norman (Eds.) Predicting Health Behavior. Buckingham: Open University Press, 1996.
3. Dettwyler, K., Biocultural Perspectives. Beauty and the Breast: The Cultural Context of Breastfeeding in the United States (1995) 167-216.
4. Gatrell, Caroline. Secrets and lies: Breastfeeding and professional paid work. Social Science and Medicine (2007) 65:393-404.
5. Jacknowitz, A., Increasing Breastfeeding Rates: Do Changing Demographics Explain Them?. Women’s Health Issues (2007) 17: 84-92.
6. Johnston-Robledo, Ingrid. Indecent Exposure: Self-objectification and Young Women’s Attitudes Toward Breastfeeding. Sex Roles: A Journal of Research (2007) 56: 429-437.
7. Labbok, M. Breastfeeding: A woman’s reproductive right. International Journal of Gynecology and Obstetrics (2006) 94: 277-286.
8. Khoury, A., Moazzem, S., Jarjoura, C., et al. Breast-Feeding Initiation in Low-Income Women: Role of Attitudes, Support, and Perceived Control. Women’s Health Issues (2005) 15: 64-72.
9. Kukla, R., Ethics and Ideology in Breastfeeding Advocacy Campaigns. Hypatia (2006) 21: 157-180.
10. Li, R., Fridinger, F., Grummer-Strawn, L. Public Perceptions on Breastfeeding Constraints. Journal of Human Lactation (2002) 18(3): 227-235.
11. Marshall, J., Godfrey, M., Renfrew, M. Being a ‘good mother’: Managing breastfeeding and merging identities. Social Science & Medicine (2007) 65: 2147-2159.
12. Miracle, D., Fredland, V. Provider Encouragement of Breastfeeding: Efficacy and Ethics. Journal of Midwifery & Women’s Health (2007) 52(6): 545-548.
13. Raju, Tonse. Continued Barriers for Breast-Feeding in Public and the Workplace. The Journal of Pediatrics (2006) 148: 677-679.
14. Ryan, A., Zhou, W., Arensberg, M. The Effect of Employment Status on Breastfeeding in the United States. Women’s Health Issues 2006; 16:243-251.
15. Walker, M., International Breastfeeding Initiatives and their Relevance to the Current State of Breastfeeding in the United States. Journal of Midwifery & Women’s Health (2007) 52: 549-555.
16. Ward, L. Breasts Are for Men: Media, Masculinity Ideologies, and Men’s Beliefs About Women’s Bodies., Sex Roles (2006) 55: 703-714.
17. Young,I. Breasted Experience: The Look and the Feeling (189-209). In: Throwing Like a Girl and Other Essays in Feminist Philosophy and Social Theory. Indianapolis, IN: Indiana University Press (1990).

The Public Health System’s Contributions to Stigma and Discrimination in Mental Health Impacting Full Recoveries from Mental Illness- Jennifer Jolivet

Mental Health America defines mental illness as a “disease that causes mild to severe disturbances in thinking, perceptions, and behavior” and classifies disorders into 5 major categories: anxiety, mood, and eating disorders, dementias, and schizophrenia. Mental illnesses are extremely prevalent in the US with more than 54 million Americans suffering from 1 or more mental disorders (1). Mental illnesses can be extremely disabling, and they affect all genders, ages, and races. According to a report by the Surgeon General, mental disorders account for more than 15% of the overall burden of disease from all causes and slightly more than the burden associated with all types of cancer (2). Unfortunately, mental health has not been regarded as important as physical health, and people suffering from a mental illness have long been subjected to hostility, discrimination, and stigma (1). Stigma and discrimination can trace their roots back to the ideas of separating the mind from the body in terms of importance and treatment. These influences continue to affect thinking today because the public health system has not done an adequate job of changing public opinions created by past public health practices and the media. There are many ways the public health system has done an insufficient job with regard to managing mental illness, but there are 3 ways that are especially significant because they help continue stigmatization and make it difficult for people to receive treatment: People with mental illnesses suffer from stigmatization from health professionals, there is a huge disparity in access to service in the form of financial barriers to those that need help, and the public health system has not successfully combated the media’s negative portrayal of people with mental illness. The public health system has failed those with mental illness because mental illness in public health has not been treated with the same respect and concern as other diseases like cancer. Mental illnesses can have a significant negative impact on many people in the US, and due to this, mental illness is a public health problem that cannot be ignored by the public health system anymore (2).

Mental illnesses have long been associated with many negative stereotypes, including violence, dangerousness, unpredictability, uncontrollability, and craziness. The phenomena of mental illness stigma can be explained by the labeling theory. According to this theory, the self identity and behavior of an individual is influenced by societal norms. Society has established a set of rules that dictate what normal and usual behavior is, and those who violate the rules are abnormal. People with mental illnesses cannot always act the way society believes is correct and because of this, the general public views people with mental illness as having something wrong with them, allowing stereotypes to develop. The public’s attitudes on mental illness have been tracked since the 1950’s and not much has changed concerning stigmatization. In the 1950’s people viewed mental illness as a stigmatized condition and those with extreme behaviors, psychosis, were viewed as mentally ill and were stigmatized as unpredictable and violent (2, 3). A similar study by Phelan et al. (4) in 1996 revealed the public had an increased scientific understanding of mental illness. However, social stigma was stronger than what it had been in the past, especially concerning psychosis disorders like schizophrenia. In the 1950 study, 13% of the responders who defined mental illness to include psychosis stigmatized mental illness with violence, while in 1996, 31% of the responders did so, indicating people today still fear that those with mental illnesses are dangerous even though this idea is largely unfounded (2).

For a person with a mental illness, constantly being shunned and viewed differently by employers, health professionals, family, and strangers, no matter how minor it is, can take an emotional toll. Stigma causes people to distrust, fear, avoid, and discriminate against people with a mental illness. Those who suffer from a mental illness often do not seek treatment because of the embarrassment of being labeled mentally ill. There is shame, isolation, and blame due to stigma. By not seeking treatment, people do not learn ways to manage their diseases, greatly impacting their way of life. Mental disorders are biological in nature and not all can be cured, but stigmatization caused by labeling creates adverse effects in equality, treatment, and overall outcomes for people suffering from mental illness. The long term consequences of stigmatization prevent many people with mental illness from recovering and leading successful lives (5, 6, 7).

HISTORY OF PUBLIC HEALTH’S CONTRIBUTION TO STIGMATIZATION OF THE MENTALLY ILL IN THE US
Historically, mental illness in the public health system has not been treated as a “real” biological disease, and this mistreatment helped establish the stigma associated with it that continues today. Early on, philosophers, most notably Rene Descartes, taught people to separate the mind from the body because the mind was not as important or rational as the body and the mind acted out of passion. This thinking greatly influenced how mental illnesses were viewed and dealt with. In the 1700’s, people with mental illnesses were called “lunatics” and cared for by families with no medical intervention. In the 1800’s, social policy dictated that those with a mental illness be removed from society because they were afflicted with their disorder for violating physical, mental, and moral laws. The mentally ill were sent to asylums, which were often inhumane places where frequent mistreatment occurred (3). In the 20th century, asylums lost popularity, but just as inhumane events occurred. For example, in the 1920’s, many mentally ill patients were forcibly sterilized, and in the 1940’s and 1950’s, many received lobotomies to remove the damaged brain which often caused even more serious side effects like mental retardation (2, 3).

This separation of the mentally ill from the rest of the public affected the treatment of and attitudes toward the mentally ill. Treatment has evolved over the years from doing nothing to the many therapies and therapeutic drugs of today, but attitudes toward treatment are still very different compared to attitudes toward treatment for publicly accepted diseases like cancer and heart disease. One problem is the mental health field was the repository for disorders whose etiology was unknown. The mental health field in its early origins included diseases that had no scientific understanding or treatment, but as more was discovered about the disease, it was moved to more medically respected departments like internal medicine or neurology. This led many individuals both in the public and medical fields to believe psychiatry was not a part of medicine and not based on reliable science (2). This idea has slowly changed over the past few years, but mental disorders are still not treated equally in the medical community. Compared to other diseases such as cancer, obesity, and heart disease, mental disorders do not receive anywhere near the same level of respect and attention as they have. The public and medical fields view obesity, cancer, and heart disease as biological diseases with symptoms and that they are a burden and life-threatening. Treatment focuses on prevention and rehabilitation, and the public health system has launched numerous campaigns to educate people about eating healthy, exercising, and being pro-active in taking caring of oneself. Obesity no longer has the stigma once associated with it because it is viewed as a very serious disease. Mental disorders have not received this treatment. Even though they affect millions, are life-threatening, and a tremendous burden to more than just the affected person, mental illness is not considered a physical disease because they often do not kill an affected person like leukemia does. People have trouble believing the idea that the mind is just as susceptible to disease as the heart or lungs. A January 2000 article in US Today illustrates this point: under the title “Mental Disorders Are Not Diseases,” Thomas Szasz argues that medical diseases are discovered while mental diseases are invented because medical diseases occur from physical aliments and are diagnosed based on physical abnormalities in the body while mental diseases are patterns of personal conduct and diagnosed on behaviors alone (8). People still believe there is no need for medicine to be involved in mental disorders because the public health system has not done what it has for diseases like obesity: making it socially acceptable for people to get diagnosed and treated because they suffer from a real, serious disease that can affect everyone.

HEALTH PROFESSIONALS CONTRIBUTE TO STIGMA AND DISCRIMINATION
Separating mental health from overall health not only influenced the general public but mental health professionals as well. A reason the public has not significantly changed its opinions about people with mental illnesses is because health professionals themselves stigmatize. There are few studies on this issue, but those that have been conducted reveal a double standard within the field because health professionals do have negative views and discomfort about mental illnesses (9). A study showed psychiatrists have more negative stereotypes than the general public, classifying those with a mental illness as more dangerous, unpredictable, and unreliable compared to the general public. Despite being better educated about the diseases, health professionals also showed the same lack of interest as the general public did regarding social interaction with severely mentally ill, like those suffering from major depression and schizophrenia. Professionals also had different beliefs regarding major depression and schizophrenia, with schizophrenia being viewed more negatively (10). Many mentally ill people already face significant discrimination from the outside world and they do not need more from the people who are supposed to be helping them. Beside continuing the cycle of stigmatization, health professionals’ beliefs deter people from seeking treatment. If the health professionals already have negative thoughts and reactions to their patients, it is difficult to believe there will be unbiased and open dialog and treatment.

Health professionals also add to stigma and discrimination in the way they diagnose patients, especially with regards to culture. Mental disorders are extremely difficult to diagnosis because they rely on patients describing symptoms rather than a definitive test or x-ray. The professional has to work with what the patient describes and see how it compares to different criteria set for disorders, and clinical judgment plays a significant role in final diagnosis. Disorders lie on a continuum, so there is major room for misdiagnosis or over diagnosing (11). Even though professionals are aware of the negative aspects of being labeled mentally ill, in studies they will often misdiagnosis non-cases as being mentally ill with major depression (10). For minorities, the problems they face are increased. Schizophrenia has been shown to affect all racial groups at the same rate, yet African Americans are more than 4x more likely to be diagnosed than whites and Hispanics are 3x more likely to be diagnosed than whites (12). For Asian Americans, under-diagnosing has been suggested as a problem because of the stereotype that they are “problem free” (11). Health professionals are not examining the cultural differences that prevent people from seeking treatment, could be a reason for why treatment is not working, or could be reasonable explanation for the behavior the professional feels is “abnormal.” For example, in some cultures, it is not acceptable to look someone in the eye and a clinician could easily misinterpret this if he/she is not aware of the customs (12). These disparities make mental health treatment appear uninviting, inappropriate, and ineffective (11). If patients do not trust their doctor or believe the doctor did not really listen to what they described, it is reasonable to understand why many people do not seek treatment. The lack of effective communication is a huge problem that prevents people with a mental illness from receiving proper, successful treatment.

To combat these problems that make it difficult for the mentally ill to receive treatment, health professionals need to be better trained and understand their own biases and how they affect treatment. They have to realize how their stigmatization greatly impacts their patients and the public. Professionals also need to be more aware of the cultural differences regarding race, age, and gender, and how these factors influence diagnosis and treatment. Diagnosis and treatment need to be tailored to take into account the cultural differences that influence a patient’s behavior. Creating a treatment that is geared more toward the individual should have more positive results for the person, which in turn will show others they can have more trust in the mental health services (13).

FINANCIAL BARRIERS TO TREATMENT
Isolating mental illness from the rest of the health system has had a significant impact on treatment services for disorders. By not making mental illnesses a priority, access to treatment is severely limited. Although there are numerous and very effective treatment options available for those with mental illness, the ability to pay for them is a huge barrier that prevents many from seeking a mental health specialist. Only one third of people suffering mental illness receive treatment. A survey by the American Psychological Association found Americans cite lack of any insurance coverage (87%) and costs (81%) as the major reasons that keep them from seeking mental health services (14). Even those who have insurance do not often receive treatment because health insurance coverage is more restrictive for mental illnesses than it is for somatic illnesses. Fearing the high costs of long term care, private insurance companies either refuse to cover any mental illness treatment or place limits on coverage. These restrictions include low monetary caps on long term care, high co-payments and deductibles, and low monetary caps on annual care. Medicaid and Medicare place similar restrictions on their mental health coverage. Compared to other general health services, those seeking mental health services pay substantially more out of pocket expenses and face a greater risk of suffering a catastrophic financial loss when care costs exceed insurance limits. Economic study models describe this disparity: for a family with mental health expenses of $60,000 a year, the out of pocket cost is $27,000 while the out of pocket medical/surgery costs are $1,800 (15). Insurance companies place people with severe, chronic mental illnesses in a difficult situation where they have to decide whether they take the financial hit and pay for treatment or do not receive treatment because the money has to go somewhere else. These financial barriers prevent many people from seeking and staying in treatment. The lack of interest in making treatment accessible to more individuals with mental illnesses re-enforces the idea that mental illness is not as important as other diseases.

The public health system has to address these financial barriers that are preventing treatment. It is hard to imagine only being allowed to go to the doctor three times if one was diagnosed with breast cancer, but it does happen for those with mental illness. The Paul Wellstone Mental Health and Addiction Equity Act is currently being debated in Congress, and the public health system should be actively campaigning for the passage of this legislation. It aims to stop the discrimination in the treatment of mental illnesses by prohibiting treatment limits and increased financial requirements insurance companies impose on those receiving mental health services (16). Some states have laws that require mental health financing to be on the same level as financing for general health services, and studies indicate total health care costs barely go up. The public health system should use this information to initiate changes in the laws by educating people on the idea that better services will not be as financially burdensome as insurance companies suggest (15).

THE PUBLIC HEALTH SYSTEM IS NOT SUCCESSFULLY CHALLENGING STIGMA
The historic impact of mental illness stigma is still felt today in many ways, and the public health system has begun to realize they have to actively challenge the stigma the mentally ill continually face. They have launched many anti-stigma educational campaigns, but these actions are not enough because stigmatizing opinions are not related to knowledge. As studies show, mental health professionals stigmatize even though they are highly educated on the subject (10). The public health system is failing to use one of the most influential sources to reverse the damage of stigma: the media. The public health system fails in two ways with regards to the media: it has not prevented the media from continuously portraying the stereotypes of mental illness, and they are not affectively using the media to change public opinion. The media plays a tremendous role in stigmatization because it is the primary source of information about mental illness for many Americans. Unfortunately, the media does not always positively portray mental illness and constantly links people with mental disorders with violent behavior and provides inaccurate information on mental disorders. Newspapers overwhelming focus on the dangerousness and criminality of people with a mental illness. A study in 1994 examined 184 prime time shows and found the mentally ill characters were 10 times more violent than the general population of characters, and in crime dramas, the offender had a mental illness in over 50% of the programs. People with mental illness were also portrayed as childlike, laughable, narcissistic, and lazy (17; 18). Rarely is there a mentally ill person who is the hero of a storyline. There is no disclaimer at the end of show where a schizophrenic person was the killer saying this is not the norm. The media reinforces what the general public wrongly believes about the mentally ill, and the public health system has not done a sufficient job in challenging what the media is doing. They are not protesting what is on the shows or providing alternative positive images of the mentally ill, allowing the media to continue supporting stereotypes.

The public health system is not affectively challenging the media because it is failing to understand why the media portrays the mentally ill as it does. The public health system runs an anti-stigma ad but then the show that follows has a mentally ill person committing heinous crimes. The public health system is competing with the media rather than working with it to get more accurate information out, and they do not appear to be taking into account how influential the media is. By not understanding the types of messages the media is releasing and the reasons for it, the public health system will have a difficult time getting people to be more accepting of the mentally ill. Education alone is not going to reduce stigma because the stereotypes are too deep in the social system. The public health system has to realize that using the media to provide images that portray the mentally ill as real people is an effective way to help people overcome their stigma. This includes having characters that have different disorders not just the most feared ones like schizophrenia and showing how they really function in society as well as not always making the mentally ill the bad guy (17).

There are many examples the public health system can look at to develop a better anti-stigma campaign. For example, tobacco is an example where the media has helped change what is socially accepted behavior. In movies and television, smoking by major characters is not as common as before. Educational campaigns focus on giving the public power to demand change and take charge rather than using fear or blame. This model could be used to create messages that motivate people to stand up against stigma rather than scolding them for it. There are some examples in the mental health field as well. Drug companies have helped start to change opinions on depression. There are ads for treatment on television as often as ads for Viagra. The commercials are a step toward reducing mental health stigma by showing everyone can get depression but that with help, the person can take back control of his/her life. In addition, numerous celebrities have publicly come out and discussed their battle with depression in the media and how they sought treatment to overcome it. Celebrities help show people that everyone is susceptible to mental illness. They can also help reduce stigma by showing if they can acknowledge their problem as public figures, there should be no shame for regular people to do it as well. As Mike Wallace of 60 Minutes stated when discussing his severe depression, “there’s nothing, repeat, nothing to be ashamed of when you’re going through depression” (19). The public health system needs to model anti-stigma campaigns after these successful media interventions. The public health system can use the media to make the public aware, concerned, and interested in mental illness. By changing public opinions, this will initiate changes in public health policy that will allow better and more accessible treatment because mental illness will not be an afterthought with regards to health.

People with mental illnesses suffer beyond just their disease. Because of how they have been treated in the past, problems persist today. Mental health professionals contribute to the stigma, financial burdens prevent many from receiving treatment, and the public health system is not using the most effective way to reduce stigma. Mental illness affects millions of people, costs billions of dollars, and is just as devastating as other diseases; therefore it deserves the same level of attention and respect. The public health system is increasing its part in challenging stigma, but it needs to do more. Health professionals need to understand their role in stigma and how it negatively affects treatment. Mental health service should be financed on par with general health services. Making these changes in policies will help change public opinion because mental health will finally be viewed as an important aspect to overall health. The general public also needs to be educated on more than just the scientific aspects because people’s stereotypes are just too strong. Education that shows people the mentally ill are not as frightening as they thought they were is what will illicit changes. Using the media will be a powerful way to get this new message across because the media is what helped make the stigmatization so strong. Fighting stigma will help those with mental illness finally receive the quality treatment they deserve.

REFERENCES
1. Mental Health America. Stigma: Building Awareness and Understanding. http://www.mentalhealthamerica.net/go/action/stigma-watch.
2. Surgeon General. Introduction and Themes. In Mental Health: A Report of the Surgeon General, 1999. http://www.surgeongeneral.gov/library/mentalhealth/pdfs/c1.pdf.
3. Link, B., Phelan, J.C., Bresnahan, M., Stueve, A., and Pescosolido, B.A. Public Conceptions of Mental Illness: Labels, Causes, Dangerousness, and Social Distance. American Journal of Public Health 1999; 89: 1328-1333.
4. Phelan, J., Link, B., Stueve, A., and Pescosolido, B. Public conceptions of mental illness in 1950 in 1996: Has sophistication increased? Has stigma declined? August 1997. Paper presented at the meeting of the American Sociological Association, Toronto, Ontario.
5. SparkNotes. Introduction to Abnormal Psychology. http://www.sparknotes.com/psychology/abnormal/intro/labelingtheory.html.
6. Link, B.G., Yang, L.H, Phelan, J.C., and Ciollins, P.Y. Measuring Mental Illness Stigma. Schizophrenia Bulletin 2004; 30: 511-541.
7. Lamb, H.R. Review of Being Mentally Ill: A Sociological Theory, 3rd ed., by Thomas J. Scheff. American Journal of Psychiatry 2002; 159: 513-514.
8. Szasz, T. Mental Disorders Are Not Diseases. USA Today (Society for the Advancement of Education). January 2000. http://findarticles.com/p/articles/mi_m1272/is_2656_128/ai_58576581.
9. Sriram, T.G., and Jabbarpour, Y.M. Are Mental Health Professionals Immune to Stigmatizing Beliefs? Psychiatric Services 2005; 56: 610.
10. Nordt, C., Rossler, W., and Lauber, C. Attitudes of Mental Health Professionals Toward People with Schizophrenia and Major Depression. Schizophrenia Bulletin 2006; 32: 709-714.
11. Surgeon General. The Fundamentals of Mental Health and Mental Illness. In Mental Health: A Report of the Surgeon General, 1999. http://www.surgeongeneral.gov/library/mentalhealth/pdfs/c2.pdf.
12. Vedantam, S. Racial Disparities Found in Pinpointing Mental Illness. Washington Post. 28 June 2005. http://www.washingtonpost.com/wp-dyn/content/article/2005/06/27/AR2005062701496.html.
13. Surgeon General. A Vision for the Future. In Mental Health: A Report of the Surgeon General, 1999. http://www.surgeongeneral.gov/library/mentalhealth/pdfs/c8.pdf.
14. Bossolo, L. Most Americans List Lack of Insurance Coverage for Not Seeking Mental health Services. American Psychological Association. http://www.apa.org/releases/insurance.html.
15. Surgeon General. Organizing and Financing Mental health Services. In Mental Health: A Report of the Surgeon General, 1999. http://www.surgeongeneral.gov/library/mentalhealth/pdfs/c6.pdf.
16. Wellstone Action. End Discrimination-Help Us Pass the Wellstone Bill! http://www.wellstone.org/network/article_detail.aspx?itemID=9229&catID=2796
17. Stout, P.A., Villegas, J., and Jennings, N.A. Images of Mental Illness in the Media: Identifying Gaps in the Research. Schizophrenia Bulletin 2004; 30: 543-561.
18. Byrne, P. Stigma of Mental Illness and Ways of Diminishing It. Advances in Psychiatric Treatment 2000; 6: 65-72.
19. CBS. Depression. CBS Cares. http://www.cbs.com/cbs_cares/depression/.

Individuals Alone Can’t Halt the Obesity Epidemic- How Obesity Prevention Focused on Personal Responsibility is Failing in America-Dailan Liu

The impact of obesity on health has been recognized for more than half a century, and weight reduction has been an American preoccupation for decades. Yet, the prevalence of obesity has increased sharply and continues to soar among U.S. adults and children, with no immediate signs of reversal. Nearly two-thirds of American adults are overweight or obese due to sedentary lifestyles and unhealthy eating habits (1). The rate of childhood obesity more than tripled from 1980 to 2004 (2-3). Approximately 25 million children are now either obese or overweight. In early 2000, Health & Human Services launched a small step campaign including hundreds of tips on food, eating, cooking and exercise which lead people to healthy lifestyles to control and prevent obesity. But the Obesity rates have increased by more than 60% among adults over the last 10 years. “Despite all of the emphasis focused on childhood obesity in our country during the last several years, many children and families are still not making the necessary changes to lead healthy lifestyles,” said Ad Council President and CEO Peggy Conlon (4).

Poor nutrition and physical inactivity are two identified factors that lead to obesity increasing Americans’ risk for developing major diseases, including type 2 diabetes, heart disease, stroke and some forms of cancers (5-6). According to HHS, obese and overweight adults cost the U.S. anywhere from $69 billion to $117 billion per year(7). Researchers and practitioners know a lot about nutrition and exercise. There are well agreed upon standards for basic nutrition and minimum levels of physical activity for sustaining good health (8-9). However, much less is known about how to effectively encourage people to make healthy choices. Individuals are often told to take personal responsibility and lose weight. Clearly, the strategy of focusing on personal responsibility alone is failing.

Why has obesity control failed? This is because individuals alone can’t halt the obesity epidemic. Most obesity prevention programs like the small step campaign target individual behavior change at the micro level (i.e. personal choices in relation to caloric intake, exercise, and diet composition). At the macro level, changing patterns in the global prevalence of obesity are explained in terms of broad social, environmental, and biological factors (e.g. food choice availability, occupational activity level, and biological predisposition). Obesity prevention at the international level will be most successful if they can simultaneously address both the cultural influences that motivate personal behaviors, and the macro level determinants of obesity over which the individual has little or no control. This is called the socio- ecological model (10). Using this model we can more fully understand and solve the obesity problem.

The Small Step Campaign Assumes Factual Information About Diet and Exercise Would Ignite Individual’s Behavior Change.
The small step TV ads are poorly designed, the website mostly focus on factual information with no fun. In the ad, a flat voice asks the question “Can your food do that?” which is boring and confusing. From the advertising theory we know that a successful ad is based on a great promise, which is effectively used in the food industry. Similarly the small step website is full of hundreds of tips to teach you what to eat, how to cook and how to exercise (11). People do not have an incentive to read all of the tips, let alone to return to the site again.

The small step campaign assumes that all the factual information about diet and exercise will be enough to change the individual’s behavior. The campaign is primarily based on the Health Belief Model and Theory of Reasoned Action. These two models focus on the individual’s role and responsibility to ignite behavior changes. The campaign does not address the individual’s taste preference, cultural and social economic reasons for eating unhealthy foods (12-13).
The small step campaign should have a more comprehensive vision. Clearly, unhealthy diet and lack of exercise are the two proximal factors directly causing obesity. Social and environmental factors like poverty, poorly funded schools, inadequate access to health care and community insecurity are considered distal but fundamental causes of obesity.

Personal Responsibility Strategy Lack Tools to Promote Self-Efficacy
Social Learning Theory is based on the tenet that people do not learn behaviors and make decisions in a vacuum, isolated from external interactions. They are influenced by their relationships with families, friends, neighbors, and colleagues; their home, workplace, neighborhood, and school environments; their economic limitations; and their genetics, physiology, psychology, and life stages (10). Considering the many aspects of American culture that promote obesity, the small step campaign focusing only on modifying individual behavior is not enough to reverse the current trend. Industry practices and technological advances have promoted obesity. Americans spend about half of their food budget and consume about 1/3 of their daily meals outside the home. Food eaten outside is higher in fat and lower in micronutrients than food prepared at home. There also tends to be more of it, with the standard serving sizes of certain foods increasing greatly in recent decades. For example, in the 1950s, coca-cola was packaged only 6.5oz.bottles; today single- serving containers are 20-oz. bottles.

Food promotions, pricing, packaging and availability all encourage Americans to eat more, not less. In 2000, the cost of advertising soft drinks reached $ 700 million, and for the McDonald’s restaurant chain the advertising budget topped $1 billion, dwarfing the National Cancer Institute’s $4 million annual investment in the educational component of its 5-A-Day campaign to increase consumption of fruit and vegetables (14).

Meanwhile, labor-saving devices, from automobiles to e-mail, are ubiquitous and have reduced energy needs, as has the shift of a large proportion of the workforce from manual labor to white-collar jobs that require little more activity than pressing keys on a computer. In addition, many suburban neighborhoods are geared towards automobiles, with few, if any, sidewalks to encourage walking, running and other forms of transportation and exercise. Taken together, such changes in the food and lifestyle environment help explain why it requires more than just willpower for Americans to balance their intake and output of energy.
There are hundreds of tips in small the step campaign to change the individual’s behavior, but it is not easy to stick to even some of them. The small step campaign does not address the above distal but fundamental causes of obesity assuming American live in an environment they can control very well in a life style instructed by small step tips. The outlined measures in the small step campaign cannot alone eliminate obesity from the American landscape. A possible effective method is levying small taxes on energy-dense foods or activities that could generate big revenues to be used to promote health, such as a 2/3 cent tax per 12 ounces on soft drinks (15). Without a national commitment and effective new approaches to making the environment more favorable to maintaining healthy weight, the obesity epidemic will be almost impossible to halt.

Personal Responsibility Strategies Fail to Consider the Social Economic Factors- Like Poverty, Cultural and Safety Issues
A 2005 survey of low-income children ages 2 to 5 called the Pediatric Nutrition Surveillance Survey found that 14.7% of these children are overweight (16). Thirty-nine states and Washington, D.C. participated in the survey. Obesity rates also appear to have some relationship with poverty rates in many states. Eight of the 10 states with the highest rates of poverty are in the South, where obesity rates are higher, and many of the states with the lowest poverty rates are among the states with the lowest obesity rates. Eight of the states with the highest poverty rates are also in the top 15 states with the highest obesity rates (17).
Many tips in the small step campaign emphasize ordering a small serving of food, and the use of honey instead of sugar. However low income families prefer getting large potions of food to save money. In addition these low income families do not want to pay to go to gym for exercise.

For many households, the lack of money can contribute to both hunger and obesity. Households that lack the funds to purchase enough food often have to rely on cheaper, high calorie foods than prudent diets based on lean meats, fish, fresh vegetables, and fruit. These families try to maximize caloric intake for each dollar spent, which can lead to over consumption of calories and a less healthy diet. Mini-marts packed with chips, sodas and candy bars are often more common in low-income areas. “We didn't have enough to really go shopping, so we'd go to McDonald's," "We just got junk food because it was so much cheaper and it was filling and it tastes good (18)." While obesity rates are climbing among all ages, races and incomes, evidence shows that the poor are more likely to be overweight than wealthier Americans. This is a population we want to help, but telling them to eat fresh grapes and play a bit of tennis is not going to be effective.

Lower income Americans have less access to information from health professionals, and consequently, less knowledge about how to maintain a healthy lifestyle. Immigrants from poor countries believe obesity is a sign of health due to the culture difference. People who don't know where their next meal is coming from tend to splurge when food is available. They do not want to change their behavior and life style. In addition unsafe playgrounds, community violence and poorly funded schools may also discourage physical activities.

The Social-Ecological Model (SEM) could be thought of as an onion, with one level wrapping around another. At the center of the model is the individual. At this level, we consider the internal determinants of behavior, such as knowledge, attitudes, beliefs, and skills. This is the foundational level, but the model recognizes that many external forces (interpersonal, organizational, community and society) influence these individual determinants. In order to facilitate behavior change it is important to address these external forces. This model serves as a reminder to look at all levels of influence that can be addressed to support long-term, healthful lifestyle choices (19).

Despite the obesity epidemic in the low-income group, the small step campaign focused on middle class, which is one of the reasons these interventions can not reverse or even stop the obesity epidemic. The small step campaign does not address any above fundamental social factor of obesity.

A possible approach is to create ways to distribute free or inexpensive fruits and vegetables to low-income community. An on-going program addresses this: The Robert Wood Johnson Foundation is the nation's largest philanthropic organization dedicated exclusively to improving health for all Americans. One of the programs is trying to reverse the childhood obesity epidemic by 2015 by improving access to affordable healthy foods and increase opportunities for physical activity in schools and communities across the nation (20). The Foundation's major efforts are trying to changes the policies in the community and school environments that are most effective in increasing physical activity and improving nutrition for kids. This is a good example of thinking about the obesity problem beyond the Health Belief Model and implementing the socio-ecologic Model. One good example: how this program makes healthy food available to the low-income families. The Foundation is working with The Food Trust, a Philadelphia-based advocacy organization whose mission is to ensure that everyone has access to affordable, nutritious food. The Food Trust has achieved tremendous success in bringing supermarkets back to underserved communities in Pennsylvania.

Conclusion
This article criticizes the small step campaign for obesity prevention, proposes three arguments that small steps failed to increase the public self-efficacy, ignored the fundamental causes of obesity, discuss the more effective methods to prevent obesity by implementing the social-ecologic model, which requires focusing on strategies that will work on a wide scale. 1) Individuals: Addressing obesity begins by changing everyday behaviors that relate to eating and physical activity. That means changing people’s knowledge, attitudes, and beliefs. 2) Interpersonal Groups: an important way to encourage more healthy behaviors, and give individuals the knowledge and support they need. 3) Organizations: include schools, places of employment, places of worship, sports teams. Organizations can help members make better choices about healthy eating and physical activity through changes in organizational policies and environments 4) Communities: like large organizations, able to make changes to policy and the environment to give residents the best possible access to healthy foods and places to be physically active. This means implementing changes to zoning ordinances, improvements to parks and recreation facilities, and creating ways to distribute free or inexpensive fruits and vegetables. 5) Society: This all-encompassing category involves individuals, organizations, and communities working together for change. New nutrition and physical activity legislation, statewide school policies, media campaigns, and partnerships with business and industry are just some of the ways a comprehensive strategy to address obesity and other chronic diseases takes shape on a large scale (21). If we embrace comprehensive views for the obesity problem by addressing the fundamental social factors, hopefully we can take a big step to control or even reverse the obesity epidemic (22).

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17. Low-income preschoolers prone to obesity at http://www.medicinenet.com
18. “The Regulation to Phase Out: Artificial Trans Fat,” www.citytech.cuny.edu/notransfatnyc/english/
19. The Social-Ecological Model at http://www.cdc.gov
20. The Robert Wood Johnson Foundation at http://www.rwjf.org
21. U.S. Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System Survey Data (Atlanta, GA:
U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2006).
22. T.A. Wadden, K.D. Brownell, and G.D. Foster, “Obesity: Responding to the Global Epidemic,” Presentation, 8 January
2004. From an article originally published in Journal of Consulting and Clinical Psychology 70, no. 3 (June 2002): 510-
525.

Talk about Addiction: Starting the Conversation or Enforcing Social Stigma? – Meghan Gavaghan

Addiction is a topic that is discussed often in public health. This disease engenders much research into prevention and treatment and its effects on the person, family, and community of those afflicted. In an effort to increase awareness of addiction as a disease, the Department of Public Health in Massachusetts, Bureau of Substance Abuse Services, is currently running public service radio announcements. These announcements serve to raise awareness of substance abuse and the inability of those addicted to get the services they need because of the social stigma attached to the condition. It is quite admirable for the Bureau of Substance Abuse Services to attempt to institute this kind of shift in public opinion that is certainly a barrier faced by people who need treatment to recover from dependency on drugs and alcohol. The method in which the Bureau goes about trying to shift the frame of the discussion of the treatment of substance dependency, however, ultimately is not effective in its implied goal of changing the social norms and stigmas associated with addiction and increasing the access to treatment. The Bureau’s apparent attempt at utilizing the Health Belief Model, its attempt at using communications theory, and its focus only on the social stigmas associated with addiction as the only barrier to accessing treatment all conspire to limit the campaigns overall effect on changing the social stigma associated with addiction and allowing more people to receive the treatment they desire.

The Talk About Addiction program instituted by the Massachusetts Department of Public Health, Bureau of Substance Abuse Services, is ambitious in its goals. In addition to running radio announcements on radio stations in the greater Boston area (see Appendix I), a website supports further learning and online tools to encourage the general public to think differently about addiction (1). The announcements provide dramatic examples of the labels and derogatory language that is often used to describe those with substance dependence. The intended audience appears to be those in the general public that have the belief that substance dependence is within the control of the user and is not a disease that can be treated like any other disease. This, however, is not clearly stated in the announcement, but rather is left up to the listener to interpret whether or not the announcement applies to them. In addition to personal accounts, the announcement discusses the current discrepancy between those who suffer from substance abuse and those that seek treatment. As stated in the announcements and cited on the website, “Only one out of ten Americans with drug and alcohol problems will get the help they need…” (1) and further states that, “…together, we can change this troubling statistic,” (1). The announcement further direct listeners to http://www.talkaboutaddiction.org in order to get more information on addiction and how to best help those who need treatment services. The website provides further personal accounts, information on prevention, information regarding stigma and how stigma affects the treatment of substance dependence, and treatment avenues for those dependent on substances. The website also pays particular attention to the role of health care providers and employers in recognizing addiction and treating those with dependence with dignity devoid of stigma.

There are some clear limitations to the program that should be discussed prior to delving further into the effect that this intervention has on achieving the goal of alleviating the social stigma associated with substance dependence. First, the radio announcement was broadcast on an AM radio news station (WBZ1030, Boston) which may limit the number and demographic of people who hear the announcement. Secondly, the announcement itself does little to inform the public on stigma and substance dependence and relies on the website to convey information. Lastly, access to the information within the Bureau’s website is incumbent upon one’s access to the internet. This could limit those who are in fact exposed to the information meant to change the social stigma. Looking beyond the surface level of the intervention, however, it appears as though the Bureau’s program could be effective in starting the conversation with regards to eliminating the stigma attached to substance dependence and allowing those who need treatment to get it. A closer look at the behavior models and theories that appear to be behind the development of the intervention, though, shows that the Massachusetts Department of Public Health, Bureau of Substance Abuse Services, fails to effectively use social science theory to inform its intervention and therefore fails to shift the conversation away from stigmatization of those with substance dependence.

Before further discussing these limitations, it is important to discuss the link between stigma and substance dependence and the subsequent diminished access to treatment. Social stigma was characterized in an essay in the Lancet in February of 2006 by Link and Phelan as arising from 5 components. These components include labeling a person as different, linking that different person to undesirable characteristics, and then separating that different person from oneself, or stigmatizing. The different person then experiences discrimination based on those perceived undesirable characteristics, which is followed by a loss of social, cultural, economic, or political power (2). Further describing the effect of stigma, researchers have shown through a study of the societal framing of a diagnosis of mental illness or substance abuse that, “…both conditions were ranked as among the most stigmatized of 18 conditions, roughly on par with being ‘dirty and unkempt’ and having a ‘criminal record for burglary’,” (3). As a result of these stigmas, Link and Phelan go on to discuss the fact that the loss of power or control over one’s destiny puts the individual, who is already suffering from the disease of addiction, at a greater disadvantage in seeking redemptive treatment. Clearly, stigma of this magnitude that is perpetuated in society is a barrier to treatment faced by those with substance dependence and the Bureau of Substance Abuse Services was justified in attempting to alleviate this social burden on those persons seeking substance dependence treatment. While the Bureau of Substance Abuse Services was well-intentioned in attempting to change the conversation around substance dependence in the view of the general public, the intervention that they chose to implement failed to utilize or fully realize social science theory in a way that would effectively reach their target audience and assist those with substance dependence to truly get the help they need.

Health Belief Model – Informing or Detracting from Intervention?
In looking at the behavioral theory that this intervention could have been modeled after, it would appear that the designers were using the Health Belief Model to inform its creation. This is likely, as it is a widely utilized framework in many public health interventions (4). As discussed in Irwin Rosenstock’s summary article discussing the model, the Health Belief Model describes health behavior of the individual as a rational, balanced examination of the perceived susceptibility of a condition and the perceived seriousness of that condition weighed against the perceived benefits of and barriers to taking an action to prevent the condition (5). The inherent drawback of using the Health Belief Model is that the social aspect of decision making, in this example especially the stigma of substance dependence, is not taken into consideration during the process. As discussed by VanLandingham in his research on the influence of the Health Belief Model and the Theory of Reasoned Action on sexual practices among Northern Thai men, the author states that, “perhaps the most serious [problem] being its emphasis on the perceived costs and benefits of health behaviors and its relative neglect of personal and social factors,” (4). He goes on to say that, “One particular social factor that is difficult to incorporate into HBM…is peer group influence,” (4). In other words, an intervention developed using the Health Belief Model as a guide assumes that, when given the necessary information, a person will make a rational choice to follow that information regardless of the social pressures to do otherwise.

The disregard of the social pressures that frame the perceived costs and benefits of a health behavior is what ultimately detracts from the effectiveness of the Talk about Addiction campaign. The program is designed around the information provided to the listener of the radio announcement and the viewer of the website. It rests upon the assumption that once those listening to the announcement hear the personal struggles of those relaying their experiences of the stigma attached to substance dependence and those visiting the website see the statistics on addiction and how difficult addiction is to overcome (the perceived susceptibility and perceived severity aspects of the Health Belief Model) that they will rationally decide to treat addiction as a disease. This is in direct conflict with the widely accepted social norm that addiction is something that is completely in control of the individual and a weakness of the individual. The assumption that the testimonials will drastically change people’s opinions is misguided. One reason the testimonials may not have the desired effect is that the listener may not identify themselves as someone who agrees with the social norm that those with addictions are completely in control of their condition. The belief that substance dependence is not a treatable disease is most likely a subconscious belief that cannot be readily identified through self-reflection. Therefore, the listener may ignore the message that the radio announcement is trying to convey simply because they don’t realize that they harbor the belief that individuals are in control of their addictive tendencies. Also, the listener may not have any experience in dealing with a person with substance dependence and therefore may be unaware of the prejudices and preconceived notions that they harbor toward addicted individuals. The social norm, or the stigma associated with substance dependence, is the perceived barrier to the audience in making a change behavior and, considering the strength of stigma in society, is strong enough to dissuade any change in behavior on the part of the listener or viewer.

The Bureau of Substance Abuse Services could have improved upon the development of their intervention and reached a greater proportion of the general public by utilizing behavior theory that takes into account the importance of social norms and stigma in deciding behavior. One possible alternative would have been to consult the concept of diffusion of innovations theory to better influence a change in the social stigma associated with substance dependence. As discussed in the text by Edberg, this theory rests upon the idea that innovations, or new ideas and concepts, become part of society through a process of learning and adoption. The adoption of the new ideas begins with some smaller group of influential early adopters and then slowly diffuses throughout the society based on the success or acceptance of that new idea or concept. This theory originated in the development and acceptance of new technology, but can be applicable to social ideas as well (6). With this theory in mind, there is a body of evidence that suggests that health care providers would be an excellent group to focus on as early adopters of the idea that substance dependence is a disease that can be treated and should not be stigmatized as it currently is in society. Kay Redfield Jamison recently wrote an essay for the Lancet based on her own experience of mental health and substance dependence and the lack of clear understanding of these conditions as disease in the health care practitioner community. As she discussed when referring specifically to mental illness, “Unless we are willing to talk about how to deal with mental illness among professionals the problem is going to remain undiscussed, creating more fear and more stigmatization…Some of the stigma associated with mental illness exists because there has been so much bad teaching and inadequate treatment over the years,” (7). This idea is further supported by Bruce Link in a research study regarding the consequences of stigma on men with both mental illness and substance dependence. In his discussion of the findings of the study, he addresses the need to recognize the stigma that exists within the health care provider community that is a significant obstacle to treatment. He states, “Health care providers are therefore faced with the challenge of how to address stigma in its own right if they want to maximize the quality of life for those they treat and maintain the benefits of treatment beyond the short term,” (8). While focusing the intervention of the Bureau of Substance Abuse Services to a much more narrow audience of just health care providers, it could have more impact on actually changing public perception. Health care practitioners are respected members of society and if they begin the process of shifting the stigma of substance dependence, the general public is more likely to find it acceptable to treat substance dependence in that way, as well.

Radio – Effective Communication or Ineffective Source?
Despite the shortcomings of the Bureau of Substance Abuse Services apparent reliance on the Health Belief Model to inform the development of their intervention, the Bureau did make an excellent decision in attempting to use communications theory to enhance the effectiveness of the intervention. As discussed in the text by Edberg, communications theory, “aims to impact the agenda of what people are concerned about, in order to set the stage for or prompt action,” (6). By utilizing the media of radio to transmit the message of the intervention, the Bureau is attempting to set the agenda regarding the stigma associated to substance dependence and get the general public to think about the way we as a society treat those with dependence. On the surface, this seems like a very effective method of communication. In the radio announcements, very personal and impactful stories convey the damage that stigma can have on the treatment process for those dependent and those testimonies serve to try to persuade the general public to think differently about dependence.

It may be very difficult for the general public to identify with those in the radio announcement, however, because they are simply hearing a voice and not seeing the person. A major aspect of communications theory, as discussed by Edberg, is the encoding of information by the sender of the information (the Bureau) and the decoding of that information by the receiver (the general public). In the case of the Bureau’s message, the intent of the Bureau is that the general public will identify with the voices in the radio announcements and sympathize with the testimonials given with regards to the stigma associated with substance abuse. This emotional reaction to the radio announcement will encourage them to then shift the attitudes and stigmas they have associated with substance dependence. Edberg discusses the importance of choosing the proper channel within media to convey the message, as this is essential to the proper decoding of the message given by the Bureau. There is certainly a difference between reading a newspaper announcement, hearing a radio announcement, and viewing a television announcement. Edberg notes that, “selection of channels is important in health communications because, as we have noted, the channel itself is relevant to the meaning of the message and because some channels are better than others for reaching a particular group,” (6). The choice of the Bureau of Substance Abuse Services to utilize radio announcement rather that television limits the ability of the audience to decode, or interpret, the message that is being conveyed within the announcement.

The importance of the medium of communication is further supported in The Psychology of Radio, a book focused specifically on radio and its effect as a form of media. When discussing the limitations of radio, the author specifically mentions the lack of a visual element in diminishing the effectiveness of radio in advertising. He states, “Many products are much more significantly presented to the reader through photographs or artistic delineation than spoken word. No verbal portrait alone can do justice to stream-lined automobiles, to a pearl necklace, to the new styles of Paris…..pictorial reproduction of the product provides a valuable identifiability that radio cannot achieve,” (9). While this discussion focuses specifically on advertising of product, the general concept can certainly be applied to the intervention created by the Bureau of Substance Abuse Services. The Bureau, in trying to eliminate the stigma associated with substance abuse, is relying on the stories of those afflicted by stigma to persuade the general public to change their opinions, but this persuasive effect will not reach its full potential via spoken word without visual support. The Bureau could argue that the website associated with the intervention does provide that visual component, but those in the general public listening to the radio announcement may not be persuaded enough by the verbal testimonials to even go to the website to learn more. By focusing first on the auditory message of the testimonials and then the visual message conveyed on the website, the Bureau erroneously assumes that any use of communication theory is effective, rather than focusing on the most effective media, television or print advertising. The failure of the Bureau in capitalizing on a very persuasive media of print or television media diminishes its effectiveness in achieving the goal of alleviating the stigma of substance dependence and the inability of those afflicted to receive treatment.

Stigma – The Only Barrier to Treatment?
A final criticism of the intervention developed by the Bureau of Substance Abuse Services is its focus only on the effect of stigma on the inability of those suffering from substance dependence to receive treatment and the subsequent reliance on community or societal change to enhance the ability of those suffering from dependence to get the treatment needed. As discussed earlier, the effect of stigma is quite significant on the ability of those who are dependent to seek treatment, but it is certainly not the only barrier faced. The self-efficacy of the dependent person, the inability of the person to afford treatment programs, the lack of treatment facilities in one’s area, and the responsibilities of work and family are just a few other important aspects of the decision for a dependent person to seek treatment (10). The Bureau’s focus solely on the stigma associated with substance dependence diminishes its effectiveness in the goal of allowing those affected to receive treatment because stigma may not be the primary reason that a person does not seek formal treatment. By narrowing the focus of the intervention in this way, the Bureau further alienates those who have very different reasons for not seeking treatment. One particular group for which this is a relevant issue is women who are dependent on substances. Not only are treatment programs focused on women’s health limited in number, there are myriad individual and social characteristics that limit women’s ability to access treatment beyond stigma. Copeland notes that, “…the social costs of family disruption…inadequate training of health professionals to detect problem drinking among women, lack of women-only treatment services that also provided childcare, and lack of economic resources and insurance coverage,” (10) were all cited as reasons women did not seek formal treatment for their substance dependence. Additionally, many women are the primary caregivers for dependent children and those obligations were a major obstacle for seeking treatment for 28% of women who had dependent children at the time of their alcohol and other drug problems (10). Even after considering the difficulty in finding care for dependent children, women were also concerned that they could lose custody of their children altogether. The additional social stigma of having deficient maternal instincts furthered their addictive behaviors. The author concludes the article with a call for a holistic approach to the treatment of substance dependency, focusing not only on the stigma attached to substance dependence but also the financial cost of treatment and familial disruption that can affect a woman’s choice to seek treatment. By not addressing these other barriers to treatment, the Bureau of Substance Abuse Services fails to fully realize the goal of getting addicted individuals the treatment they need.

Future Interventions – Informed by the Past, Inclusive of All
In light of the three criticisms outlined above, further study of the intervention created by the Bureau of Substance Abuse Services is necessary in determining the actual effect of the radio announcements and website on changing the stigma associated with substance dependence. Without a qualitative analysis of the general public’s views on substance dependence before and after the intervention, the criticisms discussed in this critique may not be implemented in future intervention planning. The disregard of past successes and failures in the development of public health interventions leads to the repetition of previously unsuccessful initiatives (11). Perhaps if the lessons from past campaigns had been incorporated into the development of the intervention from the Bureau, we would have seen a more focused campaign. A more effective intervention would have featured a focused approach, perhaps on health care practitioners using the theory of diffusion of innovations to diffuse the concept of substance dependence and a disease from health care practitioners to the general public. It also would have included print and television announcements featuring the persons heard in the radio announcements to enhance the general public’s decoding, or understanding, of the impact of stigma on those suffering from substance dependence. Finally, the intervention would have addressed other barriers to seeking treatment, such as the cost of treatment and child care, those subpopulations such as women face in seeking treatment to enhance the goal of increasing the accessibility of treatment. Instead, the Bureau of Substance Abuse Services has produced an intervention that is limited in its ability to change the stigma associated with substance dependence and ultimately does not increase access to treatment. Future interventions developed by the Bureau of Substance Abuse Services should be informed by these research studies and the entire breadth of socials science to enhance their effectiveness in creating social change. The Bureau of Substance Abuse Services certainly begins the conversation regarding the stigma associated with substance abuse, but the intervention does not achieve its ultimate goal of getting the substance-abusing population the treatment that they need.

APPENDIX I.
In order to further understand the method of intervention used by the Massachusetts Department of Public Health, Bureau of Substance Abuse Services, I have transcribed the three different radio announcements. You can also hear audio of the radio announcements at http://www.talkaboutaddiction.org/listen/. The first example utilizes many different voices to convey the message, while the other two examples utilize one person conveying their own life experience.

Dreams
“When you were young, did you dream about being addicted? Did you dream about having a problem with alcohol? With tobacco? With drugs? With gambling? People who struggle with addiction didn’t have that dream either. The truth is, no one chooses to be addicted because addiction is a disease, a disease that can be treated like any other and when treatment works, people do recover. Families recover. Communities recover. We need to start talking, talking about why we make people who struggle with addiction feel so ashamed. Talking about why only one out of ten Americans with drug and alcohol problems will get the help they need. Let’s start the dialogue. Learn more about how addictions affect all our lives. Visit http://www.talkaboutaddiction.org sponsored by the Massachusetts Department of Public Health, Bureau of Substance Abuse Services. Start the dialogue. Visit http://www.talkaboutaddiction.org.”

Hope
“If your mom was addicted to cocaine, to crystal meth, to marijuana, would you call her a junkie? A burnout? A pothead? I am a mother, a mother of five, and I struggled with addiction for many years. I was called all those names and more and, after a while, I believed I was that junkie, that burnout, that pothead. I believed there was no hope for me. But there was hope because addiction is a disease, a disease that can be treated. And with support and treatment, it’s possible for people, families and communities to recover. I know. I’m one of those people. Only one out of ten Americans with drug and alcohol problems will get the help they need. Together, we can change this troubling statistic. Let’s start the dialogue. Learn more about how addictions affect all our lives. Visit http://www.talkaboutaddiction.org sponsored by the Massachusetts Department of Public Health, Bureau of Substance Abuse Services. Start the dialogue. Visit http://www.talkaboutaddiction.org.”

Pain
“A drunk? A degenerate? A loser? It’s what people used to call me. People like my boss, people like my wife. After a while, I believed them and I would drink more to mask the pain. They thought I could stop on my own, that it was a matter of willpower, but addiction isn’t a choice. It’s a disease, a disease that can be treated just like any other and people do recover, families recover, communities recover. I know. I’m one of those people. Only one out of ten Americans with drug and alcohol problems will get the help they need. Together, we can change this troubling statistic. Let’s start the dialogue. Learn more about how addictions affect all our lives. Visit http://www.talkaboutaddiction.org sponsored by the Massachusetts Department of Public Health, Bureau of Substance Abuse Services. Start the dialogue. Visit http://www.talkaboutaddiction.org.”

REFERENCES
1. Massachusetts Department of Public Health, Bureau of Substance Abuse Services. Talk about Addiction. Boston, MA: Massachusetts Department of Public Health. http://www.talkaboutaddiction.org
2. Link, Bruce G. et al. Stigma and its Public Health Implications. Lancet, 11 February 2006; 367: 528-529.
3. Room, Rebecca. Taking Account of Cultural and Societal Influences on Substance Use Diagnoses and Criteria. Addiction, 2006; 101 (Suppl. 1): 31-39.
4. Vanlandingham, Mark J. Two Views of Risky Sexual Practices Among Northern Thai Males: The Health Belief Model and the Theory of Reasoned Action. Journal of Health and Social Behavior, June 2005; 36 (2): 195-212.
5. Rosenstock, Irwin M. Historical Origins of the Health Belief Model. Health Education Monographs, Winter 1974; 2 (4): 328-335.
6. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston, MA: Jones and Bartlett Publishers. 2007.
7. Jamison, Kay Redfield. The Many Stigmas of Mental Illness. Lancet, 11 February 2006; 367: 533-534.
8. Link, Bruce G. On Stigma and Its Consequences: Evidence from a Longitudinal Study of Men with Dual Diagnoses of Mental Illness and Substance Abuse. Journal of Health and Social Behavior, June 1997; 38 (2): 177-190.
9. Cantril, Hadley. The Psychology of Radio. New York, NY: Harper & Brothers. 1935.
10. Copeland, Jan. A Qualitative Study of the Barriers to Formal Treatment Among Women Who Self-Managed Change in Addictive Behaviours. Journal of Substance Abuse Treatment, 1997; 14 (2): 183-190.
11. Hallfours, Denise. Fighting Back Against Substance Abuse: Are Community Coalitions Winning? American Journal of Preventative Medicine, 2002; 23 (4): 237-245.